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Nurse - Prior Authorization
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Nurse - Prior Authorization

Job Snapshot

Employment Type Full-Time
Job Type Health Care, Nurse, Insurance
Education Graduate Degree
Experience At least 3 year(s)
Manages Others No
Industry Healthcare - Health Services, Insurance
Required Travel Not Specified

Job Description

GENERAL SUMMARY: 

This Prior Authorization Nurse conducts prospective review of authorization requests including selected specialties, medical treatments and services, elective hospital admissions, ancillary services, home care and out of area referrals. The nurse makes clinical decisions based on established criteria and regulatory requirements.  Prepares documentation and presents prior authorization requests to the Medical Director for additional review. This position works closely with the NOA coordinator to develop/review denial letters.

 

QUALIFICATIONS:

  • RN/LPN with current License in state of Arizona
  • Minimum of three (3) years of experience with hospital/provider office nursing
  • Minimum of three (3) years experience in Managed Care
  • Previous Prior Authorization experience preferred
  • Excellent verbal and written communication skills
  • Excellent organizational skills
  • Knowledge of AHCCCS and Medicare regulations
  • Knowledge of Milliman guidelines
  • Knowledge of CRS
  • Computer literate (proficient in MS Office, Excel, Word)
  • Team player with excellent attitude
  • Strong service orientation and professionalism

Job Requirements

ESSENTIAL DUTIES AND RESPONSIBILITIES:

  • Perform prior authorization process by performing clinical review of requests requiring medical review and entering authorizations into the system.
  • Provides clear and accurate documentation on rational for approving request or reason for sending to the Medical Director for additional review.
  • Handle telephone requests timely and accurately.
  • Develop and update health plan resources and forms to assist staff in their day to day functions.  Provide resources and training to prior authorization technicians upon completion.
  • Assist Case Management and Concurrent Review staff with complex cases.
  • Assist with the design and updating of PA grids and desktop processes.
  • Assist in reviewing and making revisions to department policies to assure compliance with regulatory agencies.
  • Participate in interdepartmental projects as needed.

 

CORPORATE INTEGRITY:

  • Understands and abides by all departmental policies and procedures as well as the organization’s Corporate Integrity Program.
  • We do not specifically reward practitioners or other individuals for issuing denials of coverage of service or care.
  • Financial incentives for MM decision makers do not encourage decisions that result in underutilization.
  • Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
  • Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position.
  • Abides by all applicable laws and regulations as mandated by state and federal laws and prevents being excluded or sanctioned from any state and/or federal programs as they pertain to healthcare.
  • MM decision making is based only on appropriateness of care and service and existence of coverage.
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Nurse - Prior Authorization


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